It is this agency's policy to provide equal employment opportunities without regard to age, race, color, religion, military gender preference, sex, marital status, national origin, or disability.

Applicant Name: *

Email Address: *

Present Address:

City:

State:

Zip:

Home Phone: *

Mobile Phone: *

Social Security Number: *

Are You at Least 18 Years Old?

Yes

No

Position Applying For:

Full Time

Part Time

Part Time Per Visit

Pool

Shift:

Day

Night

Evening

Weekend

Salary Requirements:

Date Available:

If you are not a US Citizen, have you the legal right to remain permanently in the US?

Yes

No

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

Yes

No

Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?

Yes

No

If Yes, give date, place and nature of each such conviction.

Are you presently charged with any violation of the law other than traffic violation?

Yes

No

If Yes, give date, place and nature of each such charge.

Educational History

Type of School: High School

Name & Location of School

Circle Last Year Attended

9

10

11

12

Graduated

Degree

Type of School: College

Name & Location of School

Circle Last Year Attended

1

2

3

4

Graduated

Degree

Type of School: College

Name & Location of School

Circle Last Year Attended

1

2

3

4

Graduated

Degree

Type of School: Other

Name & Location of School

Last Year Attended

From:

To:

Graduated

Degree

List professional licenses you possess. Indicate type of license, number and state:

List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability:

List languages spoken other than English:

List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:

In case of an emergency notify:

Relationship:

Out of state contact, if possible:

Relationship:

Work HistoryList all of your work experience beginning with the most recent job.

Company Name

Complete Address including City/State/Zip

Phone Number

Supervisor's Name

Date Started

Date Left

Type of Business

Salary

Full Time

Part Time

Per Visit

Reason For Leaving

OK to Contact Supervisor?

Yes

No

Describe your job title, responsibilities and accomplishments

Company Name

Complete Address including City/State/Zip

Phone Number

Supervisor's Name

Date Started

Date Left

Type of Business

Salary

Full Time

Part Time

Per Visit

Reason For Leaving

OK to Contact Supervisor?

Yes

No

Describe your job title, responsibilities and accomplishments

Company Name

Complete Address including City/State/Zip

Phone Number

Supervisor's Name

Date Started

Date Left

Type of Business

Salary

Full Time

Part Time

Per Visit

Reason For Leaving

OK to Contact Supervisor?

Yes

No

Describe your job title, responsibilities and accomplishments

PERSONAL REFERENCES:

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

Please review and sign

In making application for employment:

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments,financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my
character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an
investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that
either I or the facility will have the right to terminate the employment relationship at any time, with or without cause, and
with or without notice. I also understand that this status can only be altered by a written contract of employment which is
specific as to all material terms and is signed by me and the Administrator of the facility.

I understand, if I am an unlicensed person who has face-to-face patient/client contact, that the agency will perform a criminal history check per State Regulations as well as a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts
of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in
DADS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to
provide services in nursing facilities and skilled nursing facilities licensed by the Texas Department of Aging and Disability
Services (DADS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by
nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All DADS-regulated facilities
and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I
am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against
a resident or consumer and am, therefore, unemployable.

Release:

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.